Chapter 4 : General and Preoperative Care
Preoperative care is the preparation and management of a patient prior to surgery.
It includes both physical and psychological preparation.
Preoperative care involves many components, and may be done the day before surgery in the hospital, or during the weeks before surgery on an outpatient basis.
The anticipated outcome of pre-operative care is a patient who is informed about the surgical course, and copes with it successfully.
The goal is to decrease complications and promote recovery.
Patients who are physically and psychologically prepared for surgery tend to have better surgical outcomes.
Preoperative care is extremely important prior to any invasive procedure, regardless of whether the procedure is minimally invasive or a form of major surgery.
Physical preparation may consist of a complete medical history and physical exam, including the patient's surgical and anesthesia background.
Laboratory tests may include:
Topics covered in this snack-sized chapter:
- Complete blood counts should be performed on all patients.
- Serum Electrolytes should be done on all patients over 40 year.
- A Coagulation Screen if there is a history of bleeding disorder or on anticoagulation therapy.
- An Electrocardiogram should be done on all patients over 40year.
- A Chest x-ray is required in all patients with symptomatic pulmonary disease or underlying malignancy.
The patient should also provide a list of all medications, vitamins, and herbal or food supplements that he or she uses.
Psychological preparation can be especially beneficial for patients who are critically ill, or who are having a high-risk procedure.
The family needs to be included in psychological preoperative care.
Patients and families who are prepared psychologically tend to cope better with the patient's postoperative course.
- Urinalysis is required in all patients.
The patient's or guardian's written consent for the surgery is a vital portion of preoperative care.
Informed consent supports the rights of a patient to make decisions about his or her own healthcare.
By law, the physician who will perform the procedure must explain the risks and benefits of the surgery, along with the other treatment options.
Patients who are mentally impaired, heavily sedated, or critically ill are not considered legally able to give consent.
Preoperative teaching includes instruction about:
Instruction about the preoperative period deals primarily with:
- Preparation leads to superior outcomes since the goals of recovery are known ahead of time, and the patient is able to manage post-operative pain more effectively.
- Where the patient should go on the day of surgery
Instruction about the surgery itself includes:
- How to prepare for surgery
- Informing the patient about what will be done during the surgery.
Pre-operative instruction should include information about the pain management method that they will utilize post-operatively.
Nutrients are the substances that are not synthesized in the body in sufficient amounts and therefore must be supplied by the diet.
A fundamental goal of nutritional support is to meet the energy requirements for:
- How long the procedure is expected to take.
- Core Temperature Maintenance
Preoperative refeeding can reduce the risk of postoperative complications in malnourished patients but provides no benefit to healthy, well-nourished surgical patients.
Significant reductions in morbidity with the use of preoperative nutritional support are seen only in patients with severe under nutrition.
Preoperative nutritional support should be considered for patients who are below the fifth percentile in weight for age or who have a recent 10% weight loss.
In the fasting postoperative patient, skeletal muscle protein is mobilized to provide protein for acute-phase reactants and wound healing.
Energy is supplied mainly by mobilizing fat stores.
Following are the routes of administration for the surgical patients depending on the situation of the patient:
The enteric route is safer and cheaper and is preferred whenever nutritional support is required, if the GI tract is functional.
- Energy giving (carbohydrates; proteins & fat)
This type of nutrition can be started 6–8 hour following surgery and has a few risks such as:
Adequate nutrition can be provided in liquid or semisolid form via nasogastric tubes even in patients who are unable to chew or swallow.
Enteral nutrition is preferred over parenteral nutrition as its mode of administration is not very invasive and has fewer chances of inducing infection.
Enteral feeding is considered helpful in:
- Tendency to cause abdominal cramps.
- Massive Small Bowel Resection.
- Liver failure and severe Renal Dysfunction.
Malposition and blockage of tube.
Parenteral nutrition involves the continuous infusion of a hyperosmolar solution containing necessary nutrients through an indwelling catheter inserted into the superior vena cava.
Patients who receive enriched parenteral nutrition have demonstrated better and faster recovery rates and lower complication and morbidity rates.
Total Parenteral Nutrition (TPN) is indicated when:
Complications of Enteral Feeding:
- The GI tract is not accessible or not functioning.
TPN is often preferred because critically ill patients require a lot of nutrients and cannot tolerate large fluid infusions.
TPN solutions are designed to include all the basic nutrients that patients require for maintenance of:
- Oral or enteral feeding does not meet the patient’s nutritional needs.
Technical Complications include:
Metabolic Complications include:
Complications of Parenteral Nutrition
- Carbon dioxide retention.
- Respiratory insufficiency.